key: cord-311654-ixn65hxb
authors: Zumla, Alimuddin; Azhar, Esam I.; Shafi, Shuja; Memish, Ziad A.
title: COVID-19 and the scaled-down 2020 Hajj Pilgrimage - Decisive, logical and prudent decision making by Saudi authorities overcomes pre-Hajj public health concerns
date: 2020-08-08
journal: Int J Infect Dis
DOI: 10.1016/j.ijid.2020.08.014
sha: 
doc_id: 311654
cord_uid: ixn65hxb

nan

The abrupt appearance of SARS-CoV-2 as a novel lethal zoonotic pathogen causing disease in humans in late December, 2019 (WHO, 2020) , and its explosive global spread caught health authorities worldwide by surprise and exposed the ill-preparedness of global public health systems worldwide to deal with the appearance of a new pathogen.

Apart from generic prevention and control issues of public health and lockdown measures to limit epidemic spread, specific issues of Mass Gathering (MG) sporting and religious events came under specific spotlight (Alzahrani et al, 2020; Baloch et al, 2020; McCloskey et al, 2020; .

Mass Gathering events present important health challenges related to the public health services and health of the host country population, the attendees and their home countries (Memish et al, 2014; Memish et al, 2019) . The 2009 Hajj was held during the 2009 HIN1 influenza pandemic and focused attention on developing Mass Gatherings Medicine as a formal discipline, resulting in the formation of a coalition of global academic and public health faculty and virtual WHO mass gathering collaborating centres to guide development of, and update, optimal public health and medical prevention and treatment guidelines at mass gathering events (Memish et al, 2014) .

WHO with global MG partners, developed comprehensive key recommendations for COVID-19, and since end of February, 2020, there was a stepwise increase in cancellation, temporary suspension or postponement of international and national religious, sporting, musical, and other MGs, as countries worldwide took public health and other measures (WHO, 2020b; McCloskey et al, 2020; Petersen, McCloskey et al, 2020) . Apart from focus on major sporting J o u r n a l P r e -p r o o f events, global focus has been on Saudi Arabia and the Umrah and Hajj pilgrimages.

Approximately 10 million people from 182 countries travel to Saudi Arabia annually for the Hajj and Umrah pilgrimages (Memish et al, 2014; 2019) . The Umrah pilgrimage can be performed anytime during the year Saudi Arabia with its extensive experience and commitment to pilgrim safety and wellbeing, was quick off the mark and on February 27th, 2020, restricted inbound flights and local and international pilgrims were prevented from travelling to Makkah and Madinah for the Umrah pilgrimage.

For the July 2020 Hajj approximately 2.4 million pilgrims were expected in Saudi Arabia (Saudi Ministry of Hajj and Umrah, 2020) but they knew that the growing COVID-19 pandemic may put their plans into disarray. The Saudi Ministry of Health made regular announcements that the format of the Hajj 2020 was being debated and evaluated based on COVID-19 situation globally and domestically. Several countries from where large numbers of Muslim pilgrims originate (Malaysia, Indonesia, India and Singapore) subsequently announced that they were barring their pilgrims from attending the 2020 Hajj. These cancellations were anticipated to have major social and economic impacts on national economies, individual livelihoods and on public morale. The Umrah and Hajj pilgrimages together generate over $12 billion annually for businesses and the economy and limiting or cancelling the Hajj would come at a huge cost.

Alzahrani et al (2020) 

In early June 2020, after careful consideration, the Saudi government took decisive, logical, logistical and prudent decisions (Saudi Ministry of Hajj and Umrah, 2020) to overcome these pre-Hajj nightmares of public health, political, economic and religious concerns. For the first time since the Kingdom of Saudi Arabia was formed in 1932 the decision to bar pilgrims arriving in Saudi Arabia from foreign countries was made. The 2020 Hajj was scaled down considerably, and participation for Hajj rituals restricted to only 1,000 people with a negative COVD-19 test, residing within the Kingdom of which 'foreign' residents would comprise two thirds of all selected pilgrims from a pool of local workers, health care workers and security personnel especially those who had recovered from COVID-19. Those aged 65 years and over and those with co-morbid conditions would be barred. Whilst all holy sites would remain open, adequate physical distancing and disinfection measures were put in place with J o u r n a l P r e -p r o o f oversight and assistance at regular intervals during the pilgrim's journey. Wearing masks was mandatory and pilgrims would be subject to temperature checks and placed in quarantine if required. All pilgrims were given well thought out kits that include disinfectants, masks, a prayer rug, the ihram (a seamless white garment required to be worn by pilgrims), sterilised pebbles for the stoning ritual at Jamaraat. Throughout the pilgrims would have to keep a social distance of one and a half meters and were guided by well laid out markers and Hajj coordinators. No pilgrims would be allowed to touch the Kaaba or kiss the black stone at its corner -both of which are regular customs during the Hajj. Pilgrims would also have to be quarantined for 14 days after the pilgrimage.

The Hajj 2020 was a public health success and ended on Monday 3 rd August, 2020. The decisive, logical and prudent decision making by Saudi authorities which enabled the pre-Hajj nightmare of public health, political, economic and religious concerns to be overcome. The successful completion of the 2020 Hajj is a major tribute to the leadership and commitment of the Saudi authorities, and it reflects their extensive experience of organising the annual Hajj pilgrimage, and continued commitment to improvement public health issues related to mass gatherings events. The decisive actions, public health preparedness and strict implementation of public health prevention and intervention measures, pre-Hajj, during Hajj and post-Hajj, serves as an exemplar for other mass gathering religious and sporting events.

The 2020 Hajj was not the first time the Hajj has been scaled down. Historically, the Hajj has been scaled down several times before due to infectious diseases outbreaks. Between 1830 and 1930, there were at least 27 cholera outbreaks among pilgrims in Mecca (Peters F,1994) .

Massive cholera outbreaks throughout the 19 th century resulted in the suspension of Hajj in 1837 and 1846. The cholera outbreak in 1865 in Saudi Arabia led to establishment of quarantine ports to limit the spread of the disease during Hajj. Since Saudi Arabia's foundation in 1932 the Hajj has never been cancelled and has not missed any year.

The ongoing SARS-CoV-2 pandemic, yet once again, highlights the continuing threat of new emerging infectious diseases with epidemic potential, including the persistent threat of the Middle East Respiratory Syndrome (MERS) (Perlman et al, 2020; Memish et al, 2020b) to global health security. As of 2 nd August 2020, there have been 17,660,523 confirmed cases of COVID-J o u r n a l P r e -p r o o f

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